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BREAST DIMPLING
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Breast dimpling
Breast dimpling—the puckering or retraction of
skin on the breast—results from abnormal attachment of the skin to underlying tissue. It suggests an inflammatory or malignant mass beneath the skin surface and usually represents a
late sign of breast cancer; benign lesions usually don’t produce this effect. Dimpling usually affects women older than age 40, but it also occasionally affects men.
Because breast dimpling occurs over a mass
or an induration, the patient usually discovers
other signs before becoming aware of the dimpling. A thorough breast examination may reveal dimpling and alert the patient and nurse to
a breast problem. (See How to examine your
breasts, pages 114 and 115.)
H
ISTORY AND PHYSICAL
EXAMINATION
Obtain a medical, reproductive, and family history, noting factors that increase the patient’s
risk of breast cancer. Also obtain a pregnancy
history because women who haven’t had a fullterm pregnancy before age 30 have a higher risk
of developing breast cancer. Has the patient’s
mother or sister had breast cancer? Has she
herself had a previous malignancy, especially
cancer in the other breast? Ask about the patient’s dietary habits because a high-fat diet predisposes women to breast cancer.
Ask the patient if she has noticed any changes
in the shape of her breast. Is any area painful or
tender, and is the pain cyclic? If she’s breastfeeding, has she recently experienced high fever,
chills, malaise, muscle aches, fatigue, or other
flulike signs or symptoms? Can she remember
sustaining any trauma to the breast?
Carefully inspect the dimpled area. Is it
swollen, red, or warm to the touch? Do you see
bruises or contusions? Ask the patient to tense
her pectoral muscles by pressing her hips with
both hands or by raising her hands over her
head. Does the puckering increase? Gently pull
the skin upward toward the clavicle. Is the dimpling exaggerated?
Observe the breast for nipple retraction. Do
both nipples point in the same direction? Is either nipple flattened or inverted? Does the patient report nipple discharge? If so, ask her to
describe its color and character. Observe the
contour of both breasts. Are they symmetrical?
Examine both breasts with the patient supine,
sitting, and then leaning forward. Does the skin
move freely over both breasts? If you can palpate a lump, describe its size, location, consistency, mobility, and delineation. What relation
does the lump have to the breast dimpling? Gently mold the breast skin around the lump. Is the
dimpling exaggerated? Also examine breast and
axillary lymph nodes, noting any enlargement.
M
EDICAL CAUSES
◆ Breast abscess. Breast dimpling sometimes
accompanies a chronic breast abscess. Associated findings include a firm, irregular, nontender
lump and signs of nipple retraction, such as deviation, inversion, or flattening. Axillary lymph
nodes may be enlarged.
◆ Breast cancer. Breast dimpling is an important
but somewhat late sign of breast cancer. A neoplasm that causes dimpling is usually close to the
skin and at least 1 cm in diameter. It feels irregularly shaped and fixed to underlying tissue, and it’s
usually painless. Other signs of breast cancer include peau d’orange, changes in breast symmetry
or size, nipple retraction, and a unilateral, spontaneous, nonmilky nipple discharge that’s serous or
bloody. (A bloody nipple discharge in the presence
of a lump is a classic sign of breast cancer.) Axillary lymph nodes may be enlarged. Pain may be
present but isn’t a reliable symptom of breast cancer. A breast ulcer may appear as a late sign.
◆ Fat necrosis. Breast dimpling due to fat
necrosis follows inflammation and trauma to
the fatty tissue of the breast (although the patient usually can’t remember such trauma). Tenderness, erythema, bruising, and contusions
may occur. Other findings include a firm, irregular, fixed mass and skin retraction signs, such as
skin dimpling and nipple retraction. Fat necrosis
is difficult to differentiate from breast cancer.
◆ Mastitis. Breast dimpling may signal bacterial
mastitis, which usually results from duct obstruction and milk stasis during lactation. Heat, erythema, swelling, induration, pain, and tenderness
usually accompany mastitis. Dimpling is more
likely to occur with diffuse induration than with a
single hard mass. The skin on the breast may feel
fixed to underlying tissue. Other possible findings
include nipple retraction, nipple cracks, a purulent discharge, and enlarged axillary lymph
nodes. Flulike signs and symptoms (such as fever,
malaise, fatigue, and aching) are common.
S
PECIAL CONSIDERATIONS
Remember that any breast problem can arouse
fears of mutilation, loss of sexuality, and death.
Allow the patient to express her feelings.
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P
EDIATRIC POINTERS
Because breast cancer, the most likely cause of
dimpling, is extremely rare in children, consider
trauma as a likely cause. As in adults, breast
dimpling may occur in adolescents from fatty
tissue necrosis due to trauma.
P
ATIENT COUNSELING
Provide a clear explanation of diagnostic tests
that may be ordered, such as mammography,
thermography, ultrasonography, cytology of nipple discharge, and biopsy. Discuss breast selfexamination, and provide follow-up teaching
when the patient expresses a readiness to learn.
If a breast-feeding patient has mastitis, advise
her to pump her breasts to prevent further milk
stasis, to discard the milk, and to substitute formula until the breast infection responds adequately to antibiotic therapy.
Breast nodule
[Breast lump]
A commonly reported gynecologic sign, a breast
nodule has two chief causes: benign breast disease and cancer. Benign breast disease, the
leading cause of nodules, can stem from cyst
formation in obstructed and dilated lactiferous
ducts, hypertrophy or tumor formation in the
ductal system, inflammation, or infection.
Although fewer than 20% of breast nodules
are malignant, the signs and symptoms of
breast cancer aren’t easily distinguished from
those of benign breast disease. Breast cancer is
a leading cause of death among women but can
occur occasionally in men, with signs and
symptoms mimicking those found in women.
Thus, breast nodules in both sexes should always be evaluated.
A woman who’s familiar with the feel of her
breasts and performs monthly breast selfexamination can detect a nodule 6.4 mm or less
in size, considerably smaller than the 1-cm nodule that’s readily detectable by an experienced
examiner. However, a woman may fail to report
a nodule because of the fear of breast cancer.
H
ISTORY AND PHYSICAL
EXAMINATION
If your patient reports a lump, ask her how and
when she discovered it and whether its size and
tenderness vary with her menstrual cycle. Has
the lump changed since she first noticed it? Has
she noticed any other breast signs, such as a
change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? If so, does she have
fever, chills, fatigue, or other flulike signs or
symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in
one breast only? Has she sustained recent trauma to the breast?
Explore the patient’s medical and family history for factors that increase her risk of breast
cancer. These include a high-fat diet, having a
mother or sister with breast cancer, or having a
history of cancer, especially cancer in the other
breast. Other risk factors include nulliparity and
a first pregnancy after age 30.
CULTURAL CUE Breast cancer incidence
and mortality are about five times higher in
North America and northern Europe than in Asia
and Africa.
Next, perform a thorough breast examination. Pay special attention to the upper outer
quadrant of each breast, where one-half of the
ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule,
noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft,
rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or
firmly fixed to adjacent tissue? Does the nodule
seem to limit the mobility of the entire breast?
Note the nodule’s delineation. Are its borders
clearly defined or indefinite? Does the area feel
more like a hardness or diffuse induration than
a nodule with definite borders?
Do you feel one nodule or several small
ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate
the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking
for asymmetry and irregularities. Be alert for
signs of retraction, such as skin dimpling and
nipple deviation, retraction, or flattening. (To
exaggerate dimpling, have your patient raise
her arms over her head or press her hands
against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the
breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that’s spontaneous, unilateral, and nonmilky (serous, bloody,
or purulent). Be careful not to confuse it with
the grayish discharge that can be elicited from
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113
the nipples of a woman who has been pregnant.
(See Breast nodule: Causes and associated find-
ings, page 116.)
M
EDICAL CAUSES
◆ Adenofibroma. The extremely mobile or
“slippery” feel of an adenofibroma—a benign
neoplasm—helps distinguish it from other
breast nodules. The nodule usually occurs
singly and characteristically feels firm, elastic,
and round or lobular, with well-defined margins. It doesn’t cause pain or tenderness, can
vary from pinhead size to very large, often
grows rapidly, and usually is located around the
nipple or on the lateral side of the upper outer
quadrant.
◆ Areolar gland abscess. A tender, palpable
abscess on the periphery of the areola caused
by an infection and inflammation of Montgomery’s glands. Fever may also be present.
◆ Breast abscess. A localized, hot, tender,
fluctuant mass with erythema and peau d’orange typifies an acute abscess. Associated signs
and symptoms include fever, chills, malaise,
and generalized discomfort. In a chronic abscess, the nodule is nontender, irregular, and
firm and may feel like a thick wall of fibrous tissue. It’s commonly accompanied by skin dimpling, peau d’orange, and nipple retraction and
sometimes by axillary lymphadenopathy.
◆ Breast cancer. A hard, poorly delineated
nodule that’s fixed to the skin or underlying tissue suggests breast cancer. Malignant nodules
commonly cause breast dimpling, nipple deviation or retraction, or flattening of the nipple or
breast contour. Between 40% and 50% of malignant nodules occur in the upper outer quadrant
of the breast.
Malignant nodules are usually nontender and
occur singly, although satellite nodules may surround the main one. Nipple discharge may be
serous or bloody. (A bloody nipple discharge in
the presence of a nodule is a classic sign of
breast cancer.) Additional findings may include
edema and dimpling (peau d’orange) of the skin
overlying the mass, erythema, accentuated
veins, and axillary lymphadenopathy. A breast
ulcer may occur as a late sign. Breast pain, an
unreliable symptom, may be present.
◆ Fibrocystic breast disease. The most com-
mon cause of breast nodules, this condition
produces smooth, round, slightly elastic nodules
that increase in size and tenderness just before
menstruation. The nodules may occur in fine,
granular clusters in both breasts or as wide-
spread, well-defined lumps of varying sizes. A
thickening of adjacent tissue may be palpable.
Cystic nodules are mobile, which helps differentiate them from malignant ones. Because cystic
nodules aren’t fixed to underlying breast tissue,
they don’t produce retraction signs, such as nipple deviation or dimpling. A clear, watery
(serous), or sticky nipple discharge may appear
in one or both breasts. Signs and symptoms of
premenstrual syndrome—including headache,
irritability, bloating, nausea, vomiting, and abdominal cramping—may also be present.
◆ Intraductal papilloma. Intraductal papillo-
ma is a small, benign nodule that grows in the
lactiferous ducts. A single larger nodule can
sometimes be palpated, but multiple diffuse
nodules usually resist palpation. Soft and poorly
delineated papillomas usually lie in the subareolar margin. The primary sign of this disorder is
a serous or bloody nipple discharge, typically
from only one duct. Breast pain and tenderness
may also occur.
◆ Mammary duct ectasia. This disorder,
which affects menopausal or postmenopausal
women, produces a rubbery breast nodule that
usually lies under the areola. It’s commonly accompanied by transient pain, itching, tenderness, and erythema of the areola; a thick, sticky,
multicolored nipple discharge from multiple
ducts; nipple retraction; and a bluish green discoloration or peau d’orange on the skin overlying the mass. Axillary lymphadenopathy may
also occur.
◆ Mastitis. In mastitis, breast nodules feel firm
and indurated or tender, flocculent, and discrete. Gentle palpation defines the area of maximum purulent accumulation. Skin dimpling and
nipple deviation, retraction, or flattening may be
present, and the nipple may show a crack or
abrasion. Accompanying signs and symptoms
include breast warmth, erythema, tenderness,
and peau d’orange as well as high fever, chills,
malaise, and fatigue.
◆ Nipple adenoma. Although similar in symp-
toms to Paget’s disease, adenomas rarely produce a deep-seated mass.
◆ Paget’s disease. Paget’s disease is a slow-
growing intraductal carcinoma that begins as a
scaling, eczematoid nipple lesion on one side.
The nipple later becomes reddened and excoriated and may eventually be completely destroyed. The process extends along the skin as
well as in the ducts, usually progressing to a
deep-seated mass.
(Text continues on page 116.)
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PATIENT-TEACHING AID
How to examine your breasts
Dear Patient:
Examining your breasts may
help detect any abnormalities
early. Perform this examination 5 to 7 days after the start
of your menstrual period. If
you’re past menopause,
choose the same date each
month. Follow the steps below, and call your physician if
you notice any abnormalities.
Undress to the waist, and
stand in front of a mirror with
your arms at your sides. Carefully look for the following:
changes in breast shape, size,
or symmetry; skin puckering
or dimpling; ulceration; lumps;
nipple secretions; or retraction
of the skin, nipple, or areola.
Repeat the inspection with
your arms over your head and
with your hands on your hips
and elbows out to the sides.
Now, examine your left
breast with your right hand.
Using the pads of your fingers, move clockwise
around your breast to feel
for lumps; don’t be afraid to
press firmly. Start at the outer
part of your breast and work
inward toward the nipple.
You may feel a ridge of firm
tissue along the lower part
of your breast; this is normal. Repeat the procedure,
examining your right breast
with your left hand. You
may prefer to examine your
breasts while standing in
the shower, with one hand
placed behind your head.
Using the pads of your fin-
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gers, feel the opposite armpit. Repeat the examination
on the other armpit. Don’t
be alarmed it you feel a
small lump that moves
freely; this area contains the
lymph glands. However,
check the size of the lump
daily. If it doesn’t go away or
if it gets larger, notify your
physician.
BREAST NODULE 115
Next, check your nipples for
secretions by gently squeezing one nipple between your
thumb and forefinger. Check
the other nipple the same
way. Notify your physician if
you see any secretions, and
describe the color and
amount.
This patient-teaching aid may be reproduced by office copier for distribution to patients. © 2011,
Lippincott Williams & Wilkins.
Now, lie down with a rolledup towel or a small pillow
under your right shoulder
and your right arm behind
your head. Using your left
hand, examine your right
breast and armpit as you did
while standing. Repeat the
procedure with your left
breast.
If you feel a lump while examining your breasts, note
if you can easily lift the skin
covering it, if the lump
moves under the skin, and if
it’s soft or hard. Be sure to
give your physician this information when you call
him.
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SIGNS & SYMPTOMS
Breast nodule: Causes and associated findings
Major associated signs and symptoms
Common
causes
Adenofibroma
Breast dimpling
Breast pain or
tenderness
•
Erythema
Fever
Lymphadenopathy
Nipple discharge
Nipple retraction
Peau d’orange
abscess
Breast abscess
(acute)
Breast abscess
(chronic)
Breast cancer
Fibrocystic breast
disease
Intraductal
papilloma
Mammary duct
ectasia
Mastitis
Nipple adenoma
Paget’s disease
S
PECIAL CONSIDERATIONS
Although many women regard a breast lump as
a sign of breast cancer, most nodules are benign. As a result, try to avoid alarming your patient further. Provide a simple explanation of
your examination, and encourage the patient to
express her feelings.
Prepare the patient for diagnostic tests,
which may include transillumination, mammography, thermography, needle aspiration or open
biopsy of the nodule for tissue examination, and
cytologic examination of nipple discharge.
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Postpone teaching the patient how to perform breast self-examination until she overcomes her initial anxiety at discovering the nodule. Regular breast self-examination is
especially important for women who have had a
previous cancer, have a family history of breast
cancer, are nulliparous, or had their first child
after age 30. (See How to examine your breasts,
pages 114 and 115.)
Although most nodules occurring in breastfeeding women result from mastitis, the possibility of cancer demands careful evaluation.
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117
Advise the patient with mastitis to pump her
breasts to prevent further milk stasis, to discard
the milk, and to substitute formula until the infection responds to antibiotics.
P
EDIATRIC POINTERS
Most nodules in children and adolescents reflect
the normal response of breast tissue to hormonal
fluctuations. For instance, the breasts of young
teenage girls may normally contain cordlike
nodules that become tender just before menstruation.
A transient breast nodule in young boys (as
well as women between ages 20 and 30) may
result from juvenile mastitis, which usually affects one breast. Signs of inflammation are present in a firm mass beneath the nipple.
G
ERIATRIC POINTERS
In women age 70 and older, three-quarters of
all breast lumps are malignant.
P
ATIENT COUNSELING
When teaching patients how to perform breast
self-examination, advise them to do the examination 5 to 7 days after the first day of their last
menstrual period.
Breast pain
[Mastalgia]
An unreliable indicator of cancer, breast pain
commonly results from benign breast disease. It
may occur during rest or movement and may be
aggravated by manipulation or palpation. (Breast
tenderness refers to pain elicited by physical contact.) Breast pain may be unilateral or bilateral;
cyclic, intermittent, or constant; and dull or
sharp. It may result from surface cuts, furuncles,
contusions, or similar lesions (superficial pain);
nipple fissures or inflammation in the papillary
ducts or areolae (severe localized pain); stromal
distention in the breast parenchyma; a tumor
that affects nerve endings (severe, constant
pain); or inflammatory lesions that distend the
stroma and irritate sensory nerve endings (severe, constant pain). Breast pain may radiate to
the back, the arms, and sometimes the neck.
Breast tenderness in women may occur before menstruation and during pregnancy. Before
menstruation, breast pain or tenderness stems
from increased mammary blood flow due to
hormonal changes. During pregnancy, breast
tenderness and throbbing, tingling, or pricking
sensations may also occur from hormonal
changes. In men, breast pain may stem from gynecomastia (especially during puberty and
senescence), reproductive tract anomalies, or
organic disease of the liver or pituitary, adrenal
cortex, or thyroid glands.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about
onset and character. If it’s intermittent, determine the relationship of pain to the phase of the
menstrual cycle. Is the patient a breast-feeding
mother? If not, ask about any nipple discharge
and have her describe it. Is she pregnant? Has
she reached menopause? Has she recently experienced any flulike symptoms or sustained an
injury to the breast? Has she noticed any
change in breast shape or contour?
Ask your patient to describe the pain. She
may describe it as sticking, stinging, shooting,
stabbing, throbbing, or burning. Determine if
the pain affects one breast or both, and ask the
patient to point to the painful area.
Instruct the patient to place her arms at her
sides, and inspect the breasts. Note their size,
symmetry, and contour and the appearance of
the skin. Remember that breast shape and size
vary and that breasts normally change during
menses, pregnancy, and lactation and with aging. Are the breasts red or edematous? Are the
veins prominent?
Note the size, shape, and symmetry of the
nipples and areolae. Do you detect ecchymosis,
a rash, ulceration, or a discharge? Do the nipples point in the same direction? Do you see
signs of retraction, such as skin dimpling or nipple inversion or flattening? Repeat your inspection, first with the patient’s arms raised above
her head and then with her hands pressed
against her hips.
Palpate the breasts, first with the patient seated and then with her lying down and a pillow
placed under her shoulder on the side being examined. Use the pads of your fingers to compress breast tissue against the chest wall. Proceed systematically from the sternum to the
midline and from the axilla to the midline, noting any warmth, tenderness, nodules, masses,
or irregularities. Palpate the nipple, noting tenderness and nodules, and check for discharge.
Palpate axillary lymph nodes, noting any enlargement. (See Breast pain: Causes and associ-
ated findings, page 118.)
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SIGNS & SYMPTOMS
Breast pain: Causes and associated findings
Common
causes
Major associated signs and symptoms
Breast
nodule
Erythema
Fever
Itching
Lymphadenopathy
Nipple
discharge
Nipple
retraction
Peau d’orange
abscess
Breast abscess
(acute)
Breast cyst
Fat necrosis
Fibrocystic breast
disease
Intraductal
papilloma
Mammary duct
ectasia
Mastitis
Sebaceous cyst
(infected)
M
EDICAL CAUSES
◆ Areolar gland abscess. A tender, palpable
abscess on the periphery of the areola may result from infection and inflammation of Montgomery’s glands. Fever may also occur.
◆ Breast abscess (acute). Local pain, tender-
ness, erythema, peau d’orange, and warmth are
associated with a nodule in the affected breast.
Malaise, fever, and chills may also occur.
◆ Breast cyst. A breast cyst that enlarges rapidly
may cause acute, localized, and usually unilateral pain. A breast nodule may be palpable.
◆ Fat necrosis. Local pain and tenderness may
develop in this benign disorder. A history of
trauma usually is present. Associated findings
include ecchymosis; erythema of the overriding
skin; a firm, irregular, fixed mass; and skin re-
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traction signs, such as skin dimpling and nipple
retraction. Fat necrosis may be hard to differentiate from breast cancer.
◆ Fibrocystic breast disease. Fibrocystic
breast disease is a common cause of breast
pain. Initially, the cysts may cause pain only before menstruation. Later in the course of the
disorder, pain and tenderness may persist
throughout the cycle. The cysts feel firm, mobile, and well defined. Many occur bilaterally in
the upper outer quadrant of the breast, but others are unilateral and generalized. A clear,
serous nipple discharge may be present in one
or both breasts. Signs and symptoms of premenstrual syndrome—including headache, irritability, bloating, nausea, vomiting, and abdominal cramping—may also be present.
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119
◆ Intraductal papilloma. Unilateral breast
pain or tenderness may accompany intraductal
papilloma, although the primary sign is a serous
or bloody nipple discharge, usually from only
one duct. Intraductal papilloma is the primary
cause of nipple discharge in nonpregnant, nonlactating women. Associated signs include a
small (usually 1.5- to 3-mm), soft, poorly delineated mass in the ducts beneath the areola.
◆ Mammary duct ectasia. Burning pain and
itching around the areola may occur, although ectasia usually produces no symptoms initially. The
history may include one or more episodes of inflammation with pain, tenderness, erythema, and
acute fever (or with pain and tenderness alone),
which subside spontaneously within 7 to 10 days.
Other findings include a rubbery, subareolar
breast nodule; areolar swelling and erythema;
nipple retraction; a bluish green discoloration or
peau d’orange of the skin overlying the nodule; a
thick, sticky, multicolored nipple discharge from
multiple ducts; and axillary lymphadenopathy. A
breast ulcer may occur in late stages.
◆ Mastitis. Unilateral pain may be severe, par-
ticularly when the inflammation occurs near the
skin surface. Breast skin is typically red and
warm at the inflammation site; peau d’orange
may be present. Palpation reveals a firm area of
induration. Skin retraction signs—such as
breast dimpling and nipple deviation, inversion,
or flattening—may be present. Systemic signs
and symptoms—such as high fever, chills,
malaise, and fatigue—may also occur.
◆ Sebaceous cyst (infected). Breast pain may
be reported with this cutaneous cyst. Associated
findings include a small, well-delineated nodule;
localized erythema; and induration.
S
PECIAL CONSIDERATIONS
Provide emotional support for the patient and,
when appropriate, emphasize the importance of
monthly breast self-examination. (See How to
examine your breasts, pages 114 and 115.)
Prepare the patient for diagnostic tests, such as
mammography, thermography, cytology of nipple
discharge, biopsy, or culture of any aspirate.
P
EDIATRIC POINTERS
Transient gynecomastia can cause breast pain
in males during puberty.
G
ERIATRIC POINTERS
Breast pain secondary to benign breast disease
is rare in postmenopausal women. Breast pain
can also be due to trauma from falls or physical
abuse. Because of decreased pain perception
and decreased cognitive function, elderly patients may not report breast pain.
P
ATIENT COUNSELING
Advise the patient to wear a bra that cups and
supports the entire breast and has wide shoulder and back straps. Warm or cold compresses
may be helpful. Teach the patient how to perform breast self-examination, and instruct her
to call the physician immediately if she detects
any breast changes.
Breast ulcer
Appearing on the nipple, areola, or the breast itself, an ulcer indicates destruction of the skin
and subcutaneous tissue. A breast ulcer is usually a late sign of cancer, appearing well after
the confirming diagnosis. However, it may be
the presenting sign of breast cancer in men,
who are more apt to dismiss earlier breast
changes. Breast ulcers can also result from
trauma, infection, or radiation.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin the history by asking when the patient
first noticed the ulcer and if it was preceded by
other breast changes, such as nodules, edema,
or nipple discharge, deviation, or retraction.
Does the ulcer seem to be getting better or
worse? Does it cause pain or produce drainage?
Has she noticed any change in breast shape?
Has she had a rash? If she has been treating the
ulcer at home, find out how.
Review the patient’s personal and family history for factors that increase the risk of breast
cancer. For example, ask about previous cancer,
especially of the breast, and mastectomy. Determine whether the patient’s mother or sister has
had breast cancer. Ask the patient’s age at
menarche and menopause because more than
30 years of menstrual activity increases the risk
of breast cancer. Also ask about pregnancy because nulliparity or a first pregnancy after age
30 also increases the risk of breast cancer.
If the patient recently gave birth, ask if she
breast-feeds her infant or has recently weaned
him. Ask if she’s currently taking an oral antibiotic and if she’s diabetic. All these factors predispose the patient to candidal infections.
Inspect the patient’s breast, noting any asymmetry or flattening. Look for a rash, scaling,
120 BREATH WITH AMMONIA ODOR
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cracking, or red excoriation on the nipples, areola, and inframammary fold. Check especially
for skin changes, such as warmth, erythema, or
peau d’orange. Palpate the breast for masses,
noting any induration beneath the ulcer. Then
carefully palpate for tenderness or nodules
around the areola and the axillary lymph nodes.
M
EDICAL CAUSES
◆ Breast cancer. A breast ulcer that doesn’t
heal within 1 month usually indicates cancer.
Ulceration along a mastectomy scar may indicate metastatic cancer; a nodule beneath the ulcer may be a late sign of a fulminating tumor.
Other signs include a palpable breast nodule,
skin dimpling, nipple retraction, bloody or
serous nipple discharge, erythema, peau d’orange, and enlarged axillary lymph nodes.
◆ Breast trauma. Tissue destruction with in-
adequate healing may produce breast ulcers.
Associated signs depend on the type of trauma
but may include ecchymosis, lacerations, abrasions, swelling, and hematoma.
◆ Candida albicans infection. A severe can-
didal infection can cause maceration of breast
tissue followed by ulceration. Well-defined,
bright-red papular patches—usually with scaly
borders—characterize the infection, which can
develop in the breast folds. Cracked nipples predispose breast-feeding women to this infection,
which causes a burning pain that penetrates
into the chest wall when the infant sucks.
◆ Paget’s disease. Bright-red nipple excoria-
tion can extend to the areola and ulcerate. A
serous or bloody nipple discharge and extreme
nipple itching may accompany ulceration.
Symptoms are usually unilateral.
O
THER CAUSES
◆ Radiation therapy. After radiation, the
breasts appear “sunburned.” Subsequently, the
skin ulcerates and the surrounding area becomes red and tender.
S
PECIAL CONSIDERATIONS
Because breast ulcers become infected easily,
teach the patient how to apply topical antifungal
ointment or cream. Instruct her to keep the ulcer
dry to reduce chafing and to wear loose-fitting undergarments. If breast cancer is suspected, provide emotional support and encourage the patient
to express her feelings. Prepare her for diagnostic
tests, such as ultrasonography, thermography,
mammography, nipple discharge cytology, and
breast biopsy. If a candidal infection is suspected,
prepare her for skin or blood cultures.
G
ERIATRIC POINTERS
Breast ulcers should be considered cancerous
until proven otherwise in elderly women because of their increased breast cancer risk.
However, ulcers can also result from normal
skin changes in the elderly, such as thinning,
decreased vascularity, and loss of elasticity as
well as from poor skin hygiene. Pressure ulcers
may result from the use of restraints or tight
bras; traumatic ulcers, from falls or abuse.
Breath with ammonia odor
[Uremic fetor]
The odor of ammonia on the breath—described
as urinous or “fishy” breath—typically occurs in
end-stage chronic renal failure. This sign improves slightly after hemodialysis and persists
throughout the course of the disorder, but it isn’t
of great concern.
Ammonia breath odor reflects the long-term
metabolic disturbances and biochemical abnormalities associated with uremia and end-stage
chronic renal failure. It’s produced by metabolic
end products blown off by the lungs and the
breakdown of urea (to ammonia) in the saliva.
However, a specific uremic toxin hasn’t been
identified. In animals, breath odor analysis has
revealed toxic metabolites, such as dimethylamine and trimethylamine, that contribute to
the “fishy” odor. The source of these amines, although still unclear, may be intestinal bacteria
acting on dietary chlorine.
H
ISTORY AND PHYSICAL
EXAMINATION
When you detect ammonia breath odor, the diagnosis of chronic renal failure will probably be
well established. Look for associated GI symptoms so that palliative care and support can be
individualized.
Inspect the patient’s oral cavity for bleeding,
swollen gums or tongue, and ulceration with
drainage. Ask the patient if he has experienced
a metallic taste, loss of smell, increased thirst,
heartburn, difficulty swallowing, loss of appetite
Because GI bleeding is common in patients with
chronic renal failure, ask about bowel habits,
noting especially melena or constipation.
Take the patient’s vital signs. Watch for any
indications of hypertension (the patient with
end-stage chronic renal failure is usually somewhat hypertensive) or hypotension. Be alert for
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